CMS/OA/COO/OIT/EADG/Division of Enterprise Architecture
CMS Data Reference Model:
Data Taxonomy Description
Version 5, 2017
(formerly known as CMS Data Classification Scheme)
CMS Data Reference Model: Data Taxonomy Description TABLE OF CONTENTS
INTRODUCTION...... 3
CORE BUSINESS ENTITY DATA TAXONOMY ...... 6 BENEFICIARY & CONSUMER ...... 6 Beneficiary Attribution ...... 6 Beneficiary Benefit Utilization ...... 6 Beneficiary Cost Sharing ...... 6 Consumer Demographics ...... 6 Consumer Eligibility & Enrollment ...... 6 HEALTH INSURANCE PROGRAM ...... 7 Plan Management ...... 7 Plan Profile ...... 7 Program Evaluation ...... 7 Program Policy ...... 7 ORGANIZATION ...... 7 PROVIDER ...... 8 Provider Demographics ...... 8 Provider Eligibility and Enrollment ...... 8 Provider Participation ...... 8
MISSION SUPPORT DATA TAXONOMY ...... 9 HEALTHCARE PAYMENT ...... 9 Beneficiary Payments ...... 9 Organization Payments ...... 9 Provider Payments ...... 9 HEALTHCARE QUALITY ...... 9 Clinical Data ...... 9 Consumer Assessments ...... 9 Health Quality Measures ...... 10 Organization Assessments ...... 10 Provider Assessments ...... 10 HEALTHCARE SERVICE ...... 10
Page 1 of 11 CMS Data Reference Model: Data Taxonomy Description Communication Cases ...... 10 Diagnosis, Procedure, Product and Pricing Reference Data ...... 10 Health Service Delivery ...... 10
ENTERPRISE SUPPORT DATA TAXONOMY ...... 11 SUPPORTING RESOURCE...... 11 Administrative Resources ...... 11 Financial Resources ...... 11 Human Resources ...... 11 Information Resources ...... 11 Material Resources ...... 11
LIST OF FIGURES
Figure 1 – Data Taxonomy Structure ...... 3
Figure 2 - Subject Areas ...... 4
Figure 3 - Data Categories and Category Subtypes ...... 5
Page 2 of 11 CMS Data Reference Model: Data Taxonomy Description INTRODUCTION
The purpose of this document is to describe the purpose, structure, and content of the Centers for Medicare & Medicaid Services (CMS) Data Taxonomy. This categorization scheme is a product of the Chief Enterprise Architect and collaboratively managed with Data Administration and Engineering Services.
The Data Taxonomy is a hierarchical structure that describes the types of data that are necessary to accomplish the CMS mission. It is a three-level approach for conceptually grouping CMS data. It is used to:
• Provide a means for relating data creation and usage to other aspects of the Enterprise Architecture (e.g., business functions, IT systems) supporting business assessments and impact analyses. • Assist discovery, cataloging, and navigation of data assets and information products. • Provides a means for organizing the content of enterprise data models (e.g., Enterprise Logical Data Model, Unified Medicaid & CHIP Data Model) for use in data engineering solutions.
Figure 1 – Data Taxonomy Structure
Page 3 of 11 CMS Data Reference Model: Data Taxonomy Description The Subject Areas are the most stable level of the taxonomy, as they represent fundamental topics across CMS business lines. They reflect the overall information needs of the core mission and common business functions described in the CMS Business Reference Model (BRM).
Figure 2 - CMS Data Taxonomy: Subject Areas by Domain
Page 4 of 11 CMS Data Reference Model: Data Taxonomy Description Data categories provide recognizable subsets of the information needs represented by each subject area. They illustrate the major sets of information within a subject area. For select categories, a third level provides more business line-specific categorization.
Figure 3 - CMS Data Taxonomy: Data Categories
Page 5 of 11 CMS Data Reference Model: Data Taxonomy Description CORE BUSINESS ENTITY DATA TAXONOMY
BENEFICIARY & CONSUMER
Information about an individual in their role as it pertains to the receipt of health benefits under a CMS-administered Health Insurance Program, or private insurance coverage facilitated through CMS.
DATA CATEGORIES:
Beneficiary Attribution
Information about an individual's relationship to an entity (e.g., provider practice, Innovation Model) for the purpose of tracking aspects of care delivery and shared savings.
Beneficiary Benefit Utilization
Information about an individual's use of health care services, particularly those subject to limits, through their coverage under a CMS-administered Health Insurance Program.
Beneficiary Cost Sharing
Information about an individual's financial responsibilities for health care services. Includes payments such as premiums, co-payments, deductibles and subsidy payments.
Consumer Demographics
Information about an individual's identity, basic personal characteristics (e.g., gender, age, ethnicity), location, communication and data sharing preferences, and other attributes that may be used for eligibility and cost sharing determination.
Consumer Eligibility & Enrollment
Information about an individual's qualifications for coverage under a CMS-administered Health Insurance Program, or other minimal essential coverage through a qualified health plan.
CATEGORY SUBTYPES
Medicare FFS, MMA, Medicaid, CHIP, Supplemental Coverage, Other Minimal Essential Coverage
Page 6 of 11 CMS Data Reference Model: Data Taxonomy Description HEALTH INSURANCE PROGRAM
Information about sets of legislatively authorized health benefits and services for eligible populations. Includes regulations, policies, and coverage options.
DATA CATEGORIES:
Plan Management
Information about the organization and legal authorities under which a plan is operated. (e.g., authorizing program, operating organization)
Plan Profile
Information about a plan's characteristics such as covered benefits and services, pricing, service area, plan type (e.g., managed care) and member population demographics.
Program Evaluation
Information about a program's performance in areas such as improving care quality, lowering cost and administrative efficiency.
Program Policy
Information about the rules under which the program is operated. Category includes topics such as population eligibility criteria, benefit and service coverage, beneficiary cost sharing and provider payments.
CATEGORY SUBTYPES
Benefit and Service Coverage, Cost Sharing and Payment, Geographic Coverage, Population Eligibility, Service Delivery System
ORGANIZATION
Information about internal agency components and external organizations that serve as business agents or partners in expanding access to quality health coverage and services and enabling coordinated care at lower cost.
Page 7 of 11 CMS Data Reference Model: Data Taxonomy Description DATA CATEGORIES:
Organization Demographics
Information about an organization's identity, capabilities, relationships, financial status and health care services it may provide to populations served by CMS.
Organization Eligibility and Enrollment
Information about an organization's qualifications to operate health insurance plans, demonstrations, models or other health insurance arrangements under a CMS-administered health insurance program.
PROVIDER
Information about an individual’s or organization’s role and relationships in the delivery of health services to populations served by CMS.
DATA CATEGORIES:
Provider Demographics
Information about a provider's identity, locations, credentials, specialties, business structure and affiliations.
CATEGORY SUBTYPES
Facility Characteristics, Physician and Professional Provider Characteristics, Pharmacy Characteristics, Supplier Characteristics
Provider Eligibility and Enrollment
Information about a provider's qualifications to render health care services and receive payment under a CMS-administered health insurance program.
Provider Participation
Information about the agreements that a provider has with organizations, either directly or indirectly through another organization (e.g., network), to render health care services to plan enrollees and receive payment for those services.
Page 8 of 11 CMS Data Reference Model: Data Taxonomy Description MISSION SUPPORT DATA TAXONOMY
HEALTHCARE PAYMENT
Information about the payments made associated with the delivery of health services to populations served by CMS.
DATA CATEGORIES:
Beneficiary Payments
Information about the monies distributed to beneficiaries through a CMS-administered health insurance program. (e.g., incentive payments)
Organization Payments
Information about the monies distributed to organizations through a CMS-administered health insurance program.
Provider Payments
Information about the monies distributed to providers through a CMS-administered health insurance program.
HEALTHCARE QUALITY
Information about the measures, methods, assessments and outcomes used to evaluate the administrative and clinical quality of health service delivery.
DATA CATEGORIES:
Clinical Data
Information about an individual's clinical assessment and outcomes; gathered through claims or other medical records.
Consumer Assessments
Information about an individual's assessment, experience and outcomes related to health care delivery; gathered through surveys.
Page 9 of 11 CMS Data Reference Model: Data Taxonomy Description Health Quality Measures
Information about the quantitative tools that provide an indication of an individual's or organization’s performance in relation to a specified process or outcome via the measurement of an action, process or outcome of clinical care.
Organization Assessments
Information about an organization's performance in areas such as efficiency, process or outcomes for targeted quality measures.
Provider Assessments
Information about a provider's performance in areas such as efficiency, process and patient outcomes for targeted health quality measures. Category includes sanction and integrity information.
HEALTHCARE SERVICE
Information about the events, products and procedures associated with the usage and delivery of health services to populations served by CMS.
DATA CATEGORIES:
Communication Cases
Information about communication events such as inquiries, complaints, grievances and investigations associated with the delivery of health services to populations served by CMS.
Diagnosis, Procedure, Product and Pricing Reference Data
Information about the standard references and coding systems for identifying products and services provided during the delivery of health services.
Health Service Delivery
Information about the events, products and procedures associated with the usage and delivery of health services to populations served by CMS.
CATEGORY SUBTYPES
Managed Care Encounters, Medicaid Claims, Medicare Claims, Prescription Drug Events
Page 10 of 11 CMS Data Reference Model: Data Taxonomy Description ENTERPRISE SUPPORT DATA TAXONOMY
SUPPORTING RESOURCE
Information about the objects, places and ideas used in performing CMS’ mission, but are not unique to that mission.
DATA CATEGORIES:
Administrative Resources
Information about the administrative processes, activities and products required to carry out the day- to-day functions of CMS.
Financial Resources
Information about the costs to support the processes and activities required to carry out the day-to- day functions of CMS.
Human Resources
Information about all aspects of personnel management required to carry out the day-to-day functions of CMS.
Information Resources
Information about data, knowledge, educational materials, internal policy guides, manuals and other products used to support the activities required to carry out the day-to-day functions of CMS.
Material Resources
Information about tangible assets used to support the activities required to carry out the day-to-day functions of CMS.
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